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Steubenville Conference Application for Males June 26-28
Steubenville Conference Application for Males June 26-28
Nick Savaya
2020-02-08T12:42:42-05:00
Steubenville Conference - Male June 26-28, 2020
Steubenville Conference
All fields are required to submit application.
Retreatant Information:
Student's Full Name
*
Gender
*
Male
Female
Age on June 26
*
Grade level in Fall 2020
*
9th Grade
10th Grade
11th Grade
12th Grade
2018 Graduate
T-Shirt Size (Adult sizes only)
*
Small
Medium
Large
X-Large
XX-Large
Student and Parent Contact Information:
Student Cell Phone Number
*
Student Email
Enter Email
Confirm Email
Parent/Guardian Email Address
*
Parent/Guardian Cell Phone Number
*
Address
*
Street Address
Address Line 2
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Country
Emergency Contact Name
*
Emergency Contact Phone Number
*
Emergency Contact Relationship
Please list any allergies, medications, or any other information
Do you have a coupon code?
*
No
Yes
Coupon Code
*
Would you prefer a one-time payment or 2 monthly payments of 175?
*
One-Time Payment
Two Monthly Payments
Includes conference admission, transportation, food, lodging and 2 t-shirts. Second payment automatically charged after 1 month.
One Payment of $350
*
Price:
$350.00
Payment Includes T-Shirt, Bus, Lodging, and all meals
Two Monthly Payments
*
Price:
$175.00
*
By checking the box above, I, the authorized card-holder of the credit card entered below, authorize ECRC to automatically deduct $175 now and $175 one month from now. I will not hold ECRC liable for any unauthorized billing charges. If the payment fails the second time, I am still responsible for providing the remainder of the amount due, otherwise this registration may not be valid for attending the retreat.
Total
$0.00
Credit Card
*
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Expiration Date
Security Code
Cardholder Name
Terms & Conditions
*
There is certain behavior and certain expectations that are encouraged on this journey. I understand that this journey is to focus on my personal relationship with God. I agree that if I am found in possession of or participating in any way with drugs or alcohol, parent/guardian will be called and I will not be allowed to participate in any activities socially, only spiritually. I further understand that this is a coordinated by our Catholic Chaldean Church and I am expected to participate in all planned meetings and activities and abide by all rules. By checking the box above, I am agreeing with all terms mentioned and all my information that I completed above is true.